Case study approach to exercise prescription: one size does not fit all Samantha Breen Clinical Lead Physiotherapist Manchester Heart Centre
Aims Explain benefits of exercise training Discuss prescription for NYHA I patient Discuss prescription for NYHA III patient Considerations for symptomatic patient prescription Pacing Dysponea management
CNS -Spinothalamic tract Straining heart Dizziness, pain, arrhythmias Breathless Accessory muscle use Excess CO 2 Lactic acid Ergoreceptor ++ Deconditioned fatigue
Metaboreflex Without inspiratory muscle fatigue With inspiratory muscle fatigue Heart supplies blood in proportion to metabolic needs Fatiguing inspiratory muscles send signal to the brain Blood is diverted towards the inspiratory muscles Brain sends signal to narrow blood vessels supplying the legs Leg blood vessels constrict and blood flow decreases Leg fatigue is accelerated June 2012
Dampen down ergoreceptor and metaboreflex
A universal agreement on ex prescription in CHF does not exist; thus, an individualized approach is recommended, with careful clinical evaluation, including behavioural characteristics, personal goals, and preferences
Spectrum of HF. NYHA I-IV Meet Alan Male age 38 LVEF 45% NYHA 1 ETT 92% HRmax 10 METs Goal return to the gym and would like to return to previous power lifting Meet Jean Female age 79 LVEF 25% NYHA III FCA 6 min walk 420 meters / 2 rest stops 3 METs CR-10 RPE 5 (legs 7) Goal ADL and walking
FITT Principle FREQUENCY 2 3 x week 2 rehab classes / 1 home circuit INTENSITY TIME TYPE dependent upon assessment/ risk stratification 40-70 %HRR RPE 12-14 (6-20) or 3-5 (CR10) 20-30 mins conditioning phase plus warm up & cool down Aerobic, CV endurance training Large muscle groups
AHA/ACSM Strength Training FITT F Min 2 x per week I Upper body 30 40% 1 Rep max Lower body 50 60% 1 Rep max RPE < 15 ( Volitional Fatigue ) T 1 set min (2 to 4 sets optimal) of 10 15 reps T 8 to 10 different muscle groups ACSM, 2010
Target intensity HR 40-70% HRR RPE 12-14 (CR-10 3-5) METS 40-70% VO2 40-70% Safe and effective exercise session Warm-up 15 min Main component Total work CV or MSE 20-30min 1 hour Cool-down 10 min Resistance ACPICR, 2009
ESC (2011) Minimum recommendations of implementation of Resistance Training in CHF Programme Training objectives Intensity Reps Training vol Step I Pre-training Learn and practise 30% 1-RM. 5 10 2 3 x/wk correct implementation, RPE, 12 1-3 circuit improve intermuscular co-ordination Step II Resistance/ local aerobic endurance 30 40% 1-RM. 12 25 2-3 x / wk endurance intermuscular co-ord RPE 12 13 1 circuit Step III Strength increase muscle mass 40 60% 1-RM. 8-15 2-3 x/wk Muscle build-up 15 RPE 1 circuit intramuscular co-ord Modified according to Bjarnason-Wehrens et al.15
RPP 245 RPP 257 BP 150/80 BP 155/80 RPP 170 BP 120/80 BP 110/70 Treadmill exercise: walking Jogging Acknowledgement Professor Patrick Doherty Strength training
METS TASK METS METS (min) (max) Walking 2 mph 2 3 Dressing 2 3 Bathing 2 3 Bed Making 2 6 Walking 3 mph 3 3.5 Shower 3 4 Housework gen 3 4 Cleaning Windows 3 4 Walking Upstairs 4 7 Washing Car 6 7 Cycling 5 mph 2 3 Fishing (boat) 2 4 Billiards 2 3 Cricket 3 7.5 Ballroom Dancing 4 5 Golf (carrying clubs) 4 5 Swimming (slow) 4 5 Badminton 4 9 Swimming (Crawl) 9 10 70% max METS (10) = 7 METS Adapted from Ainsworth et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011 Aug;43(8):1575-81
Pelliccia et al (2005) Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European Heart Journal 26 (14), 1422 1445
Target intensity HR 40-70% HRR RPE 12-14 (CR-10 3-5) METS /VO2 40-70% VO2 40-70% Safe and effective exercise session Warm-up 5 min Main component Total work CV or MSE 10 min 18 mins Cool-down 3 min
ESC (2011) Minimum recommendations of implementation of Resistance Training in CHF Programme Training objectives Intensity Reps Training vol Step I Pre-training Learn and practise 30% 1-RM. 5 10 2 3 x/wk correct implementation, RPE, 12 1-3 circuit improve intermuscular co-ordination Step II Resistance/ local aerobic endurance 30 40% 1-RM. 12 25 2-3 x / wk endurance intermuscular co-ord RPE 12 13 1 circuit Step III Strength increase muscle mass 40 60% 1-RM. 8-15 2-3 x/wk Muscle build-up 15 RPE 1 circuit intramuscular co-ord Modified according to Bjarnason-Wehrens et al.15
METS TASK METS METS (min) (max) Walking 2 mph 2 3 Dressing 2 3 Bathing 2 3 Bed Making 2 6 Walking 3 mph 3 3.5 Shower 3 4 Housework gen 3 4 Cleaning Windows 3 4 Walking Upstairs 4 7 Washing Car 6 7 Cycling 5 mph 2 3 Fishing (boat) 2 4 Billiards 2 3 Cricket 3 7.5 Ballroom Dancing 4 5 Golf (carrying clubs) 4 5 Swimming (slow) 4 5 Badminton 4 9 Swimming (Crawl) 9 10 6MWT 3 METST
Importance of being accurate with prescription for low functioning and high risk patients If you increase speed of walking from 3KPH (2.4 METS) to 4 KPH (2.9 METs) Mr A max capacity is 10 METS = increase from 24% 29% of max capacity If max capacity is 4 METs = increase from 60% to 73% of max capacity
Progression Introducing steady (continuous) state Increasing ratio s of: Work: rest, CV : MSE, standing : seated Increase, Range, Reps, Rate, resistance (4R s) Once 15 mins achieved intensity may be increased Increase through step I, II and III of resistance training
Over activity / rest cycle Deterioration in function Alter prescription for good and bad days
Dyspnoea Management Breathless at rest - Seek respiratory physio advice - Tidal breathing / Pursed lip breathing - Inspiratory/expiratory ratio 1:2 (rectangle model) - Posture - Use of fan Breathing control during activity/exercise - Pace breathing with activity - Diaphragmatic breathing during active recovery - Recovery positions - Avoid breath hold / valsalva manoeuvre
Other ex considerations Safety: starting position, balance, Posture, core muscle strength Target key muscle groups for strength Importance of accuracy of prescription feet moving for venous return / avoid abrupt posture shifts limit arm ex - accessory muscle fatigue / over-head arm work swimming immersion increases LV volume/load Caution seated ex (limit venous return)
Inspiratory Muscle Training (IMT) the dumbell for your diaphragm IMT improves ex tolerance (19%) and QUOL (16%) start at 30% of max inspiratory mouth pressure (PImax) and readjust intensity every 7 10 days up to a maximum of 60%. 20 30 min/day 3 5 x week for > 8 weeks. 14/05/12 Laoutaris et al, 2004; Ribiero et al, 2009
High intensity interval training Alternate short bouts (10 30 s) of moderate high intensity (50 100% peak exercise capacity) exercise, with a longer recovery (80 60 s) phase, performed at low or no workload. VO2 peak improved by 46% high intensity interval training, compared to 14% for moderate intensity continuous training with no reported adverse events and even small improvements in left ventricular end-diastolic volumes and stroke volume. Meyer K et al 1997; Wisloff U et al, 2007.
Alan s prescription summary Aerobic Up to 70% V02 max RPE 12-14 up to 45 60 min duration Resistance training 40-60% 1-RM 8-15 reps RPE 15 Can return to most sports for which he has the functional capacity
Jean s Prescription summary Aerobic endurance Frequency Intensity Time Resistance increase to daily, several times a day reduce to lower ends of intensity target range HR 40-70%HRR METS / VO2 40-70% RPE 12-14 (CR-10 3-5) reduce 30% 1 RM 5-10 reps small muscle groups in short bouts. Posture, pacing and energy conservation Dyspnoea management strategies
In summary: NYHA I IV patients should all engage in regular physical activity / exercise Individualised prescription adapt FITT for aerobic and resistance work NYHA III / IV considerations Adapt prescription for good & bad days Energy conservation Breathing techniques
Thank you for listening Samantha.breen@cmft.nhs.uk 14/05/12
References Pina et al (2003) AHA Scientific statement. Heart Failure and Exercise. Circulation 107: 1210-1225 Pelliccia et al (2005) Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European Heart Journal 26 (14), 1422 1445 NICE Clinical Guideline No 108 (2010). Chronic Heart Failure Selig et al ( 2010) Exercise & Sports Science Australia Position Statement on exercise training and chronic heart failure. Journal of Science and Medicine in Sport 13 (2010) 288 294 Piepoli et al (2011) Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure 13, 347 357 SIGN Guideline 95 ( 2007) Management of Chronic Heart Failure
References continued Ribeiro JP, Chiappa GR, Neder JA, Frankenstein L. Respiratory muscle function and exercise intolerance in heart failure. Curr Heart Fail Rep 2009;6:95 101. Laoutaris I, Dritsas A, Brown MD, Manginas A, Alivizatos PA, Cokkinos DV. Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure. Eur J Cardiovasc Prev Rehabil 2004;11:489 496. Wisloff U, Stoylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 2007;115:3086 94. Meyer K, Samek L, Schwaibold M, et al. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures. Med Sci Sports Exerc 1997;29:306 12. ACPICR (2009) Standards for physical activity and exercise fot the cardiac population 14/05/12